Alternative Mobile Services Association Organization Membership Application
Your Name:
*
First Name
Last Name
Email Address:
*
Agency or Municipality:
Mobile service name?
Name of the mobile outreach service in your area
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number:
*
-
Area Code
Phone Number
Membership Levels
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next
( X )
Non-Profit Organization
(
$
250.00
for each
year
)
Membership level for non-profit organizations.
For-Profit Organization
(
$
500.00
for each
year
)
Membership Level for for-profit companies.
City / County Membership <100,000
(
$
500.00
for each
year
)
For cities or counties with populations UNDER 100,000 people.
City / County Membership >100,000
(
$
750.00
for each
year
)
For cities or counties with populations OVER 100,000 people
Credit Card Details
First Name
Last Name
Credit Card Number
Security Code
Card Expiration
Mobile service currently operational?
Yes
No
Under Consideration
Year founded?
Who operates the mobile service?
Police Department
Sheriff's Department
Hospital
Community Agency
City or County
Team staffed by?
nurse/EMT/paramedics
general crisis workers
peer support workers
counselor / social workers
law enforcement
psychiatrist / medical doctors
Serves?
Adults
Youth
All ages
Service model?
First Responders
Co-Responders
Plainclothes
Embedded clinician
Initial Contact
911 dispatch
Police non-emergency
3-digit number
10-digit number
By police request
Request of other agency
Self-dispatch
Service provided
Mental illness care
Addiction / alcoholism care
Street-involved / homeless
Follow-up care
Medical care
Medication support
Suicide response
Will respond to weapons / risk?
Yes
No
Funding?
City / County / State budget
Law enforcement budget
insurer / insurance
Medicaid
Philanthropy
Other Funding
Submit File(s)
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